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Nurse and Doctor, Neighbor and Friend

“Something there is that doesn’t love a wall,” begins Robert Frost’s poem “Mending Wall,” about two neighbors who meet to repair the gaps and holes in the stone wall separating their properties. They walk on either side of it, picking up and replacing fallen stones as they go.

Jeff Swensen for The New York TimesTheresa Brown, R.N.

The poem came to mind one recent day on the oncology floor where I work. It’s a medical oncology floor, where we tend to medical issues that go along with cancer, like giving chemotherapy and dealing with complications of metastatic disease. But it turned out that one of my patients had a serious surgical problem.

Surgical oncology is several flights of stairs below us. Even if they were next door, though, I imagine we’d still be inhabiting different worlds. There’s “med onc” and “surg onc,” and never the twain shall meet.

Except that sometimes they do. My patient, a middle-aged woman, had been admitted because of a blood disorder. She was also having some belly pain, so we did a CT scan. I’ve had patients in much more apparent distress, where the scan turns up nothing more than a touch of diverticulitis. But this patient had a hole in her intestine: a true medical emergency.

The next thing I knew, the patient had been put under surgical supervision, though she would stay on our medical floor for the time being. I listened, trying to learn, as the surgical attending physician talked to the medical attending physician about the patient’s blood problems, and what could be done to make it safe to operate on her. They also wanted to increase the rate of IV fluids, to make sure the patient’s blood pressure stayed high enough.

Later, as I updated one of the doctors on our floor on the patient’s latest status, a dismissive look came over his face. “Surgeons!” he scoffed, a tone I’d heard before when medical doctors talk about surgical teams, implying it’s a specialty staffed by overly aggressive people. I might have joined in his derision, except that the surgical resident newly in charge of the case was my real-life next-door neighbor.

When he had first appeared on our floor, I had greeted him warmly by his first name. It never crossed my mind that this man, who had talked helpfully to me about work, invited us to parties in his home and even taken care of my kids’ sea monkeys when we were on vacation, should be addressed as “Dr.” The familiarity drew looks of surprise from some of my fellow nurses, until I explained he lived next door.

But being neighbors at home allowed us to be more than just friendly in the hospital. It turned a potentially tense emergency collaboration into an easy professional exchange. Did the patient need a bigger IV? Should we put in a urinary catheter? How quickly could they get her into surgery? And perhaps most important, could he talk to the terrified patient and her family?

He asked me to call him on his cellphone once the patient was on her way to the operating room. It’s the kind of request you can make of a friend, or a neighbor — but not something that usually happens in the hospital, where we rely on pagers.

We all work in the same hospital, but surgeons on a medical floor can feel like strangers in a strange land. Medical staff can feel the same way on a surgery floor. We nurses in medical oncology can hang chemo and talk knowledgeably about the risks and benefits of stem cell transplants, but we’d prefer not to take care of surgical patients. Neither group understands the routines and concerns of the other as well as we might, and that gap in experience and knowledge can make staff anxious and aggressive.

“Good fences make good neighbors,” the wall-mending neighbor in Frost’s poem says, and in the hospital we seem to have embraced that idea with a vengeance. Divisions arise not just between the medical and surgical teams, but between doctors and nurses, oncologists and cardiologists, intensive care nurses and floor nurses, and friction can accompany interactions between the groups.

A few days after the operation, I went to visit the patient in the surgical intensive care unit. As I walked to her room in my white scrubs, the I.C.U. nurse grabbed my ID badge, lifting it off my chest, and said, “Who are you?”

I nervously mumbled something about having taken care of the patient on the medical floor and asked how she was doing. The nurse’s eyes slid toward the patient’s room, then narrowed in concern.

Suddenly I understood. The nurse’s look was not one of rudeness or aggression, but of worry. She seemed genuinely torn between filling me in on the patient’s condition and going back into the room, where the patient needed her care.

I nodded at her. “You’re busy,” I said, and she nodded back. I told her I’d come back at a better time.

In “Mending Wall,” the narrator goes on to challenge his neighbor’s belief that good fences make good neighbors, saying:

Before I built a wall I’d ask to know
What I was walling in or walling out,
And to whom I was like to give offence.

In the hospital, it’s as if we’re walling in our worry, and walling out potential threats to our competence. We build walls, and maintain them, to buttress our authority, and to prevent being challenged by staff from other floors.

But then one day I met my neighbor at the hospital, and suddenly the wall was down. And that, as Frost put it in another poem, made all the difference.

Both nurses and doctors are human beings and building interpersonal relationships depend on the individuals themselves.
Moreover, academic degree does not make the person but it is the environment that creates conventions that it is difficult for us to accept or live with like in your case.

Exactly the reason I have never agreed with the concept of nurses specializing in areas of nursing. Since the ultimate bottom line of health care facilities is improving the financial status of the facility, nurses have to move about to other nursing units in the facility to cover large rates of absenteeism and inappropriately low nurse to patient ratios. When this occurs, many nurses flounder in the units they float to, possibly endangering the patients that they have infrequent experience caring for. Facilitating the professional growth of nurse generalists should be encouraged, so these “walls” don’t get taller and thicker.

Thanks for that.
I needed it. The last few months have seen the AMA and AAFP just blasting NPs and PAs. I have come to look at “those guys” as people who just don’t understand how to play well in the same sandbox.
Your story gave me a bit of hope again.
Dave

Why is it exactly that it is strange that a M.D. be addressed in front of his/her colleagues by his/her first name instead of “Dr.”?

It is perplexing (?insulting?) enough that many MD’s call their patients by their first names, then insist on being addressed as “Dr.” (Even patients that ought to be addressed “Dr.” or “Mr./Ms.” as they are 50 years older that the MD.) But, why should nurses have to address them as such?

They are after all (!shock!) colleagues — and fundamentally ‘teammates’ when it comes to patient care.

What other professions do “Dr’s” demand that their non-“Dr” colleague call them by “Dr”?

For that matter, what other profession uses pagers? Doesn’t text messaging do the same thing, but provide more information?

Obviously for the New York Times there continues to exist only one voice for nurses and it is that of Theresa Brown. Are there really no ohter nurses including educators or those who work in areas other than oncology that can contribute to this newspaper. It is sad to note that even the New York Times has difficulty broadening their views on nurses and nursing

This post really struck a chord with me. We label others with whom we’re not familiar as “functions” constantly: even our colleagues become “those surgeons” or “those nurses.” And yet, when we’re reminded that we’re all people under those labels, the way we behave toward one another changes dramatically and has a real impact on important things, like the quality of care a third person receives. This spirit of abstraction is responsible, in my view, for cruelty and even the ultimate end of cruelty, war.

I enjoyed this article quite a bit… except for the misuse of the Frost poems. Frost was a realist; “Mending Wall” characterizes heavily the speaker’s neighbor as a gallumping giant who cannot think “beyond his father’s words.” The point of the poem is to show the speaker’s superiority over the neighbor–this is not the point of this article. Furthermore, the last line is taken from a poem that was written by Frost to tease a friend who always took the same path during their walks together. Frost’s point being that the paths were really just the same; this line being ironic.

As much as I liked the vignette, using these poems as a vehicle for the anecdote completely undermined this writer’s credibility (as a writer; not as a doctor. In that aspect she seems quite appealing).

Why should medical professionals be any different than the rest of us ? The territorial imperative is alive and well in all venues of life. The challenge is exposing it for what it is… behavior akin to bullying. Oh well, the human race is still evolving but it sure seems that it is in a backward swing at times, doesn’t it ?

re #10 If you think the NYT needs to print more & different nursing stories, then you should send your comments to the editor.

Theresa, I love your voice. You articulate problems that I’ve had during my career, things that the public deserves to know about.
Communication is so important, and so fraught with difficulties. Improving it is a lifelong pursuit.
Diane

Theresa, you describe in such beautiful, clear language the phenomena of walls, walling in, walling out… Then, from the comments that follow, what seems so real and important to me yields all kinds of interpretations, judgments and assessments from others. So, I get the actual experience of walls again. Peace. Peace. Peace.

Your writing is wonderful Ms. Brown (or should it be Dr. Brown, don’t you have a PhD in literature?) I love how you speak about the interpersonal relationships in medicine. I do hope your physician colleagues recognize your superior communication skills.

Oh, I recognized your name and am aware of your positive influence in the field of medicine. I am also aware that you are quite the writer and highly regarded among PAs and NPs. Perhaps the NYT has a guest spot for you! If the BMJ has published your work noting the role of PAs in medicine, certainly the NYT should be interested in enlightening its readership on PAs. By the way, I am not a PA, but a PA is my PCP.